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Aug 17 09 10:15a Reliable PetroleunnA 209-845-8953 PA <br /> • • <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 600 East Plain Street, Stockton, California 95202 <br /> Telephone: (209) 468-3420 Fax: (209)468-3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 188 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW.- <br /> El <br /> ELOW:❑ TANK RETROFIT WPIPING REPAIR/RETROFIT ❑ UDC REPAIRlRETROFIT ❑ COLD STARTIEVR UPGRADE <br /> F EPA Site# Project Contact&Telephone# 12�b Gl D`1-9 <br /> � Facility Name DA— <br /> y Phone#.9p _ jqF-aej3 f <br /> L Address `6 S 3,—E, IIAW q 97 rA, 9 S 4-5- <br /> I Cross Street <br /> T -Ay'(,,, fLo&X <br /> Y Owner/Operatore,g 4t ck TS LLC one::# a p y_ /.P/- �t 9 <br /> v(Fs <br /> o Contractor Nae Phone#2-';)Id,R - to SE <br /> N Contractor Address Si Un CALic# S 31740 44 Class <br /> R r,� <br /> A Insurer �7C CV1111y-(IYLWLC4�� work Comp# g13_003o6 F-og <br /> c ICC Technician's Name <br /> T Ub 1— Expiration Date d 9 aS <br /> R ICC Installer's Name (} 1 <br /> RJ -� Q0.Yn�'lQ,v'' Expiration Date <br /> Tank system work area Tank Size Chemicals Stored Curren Date UST <br /> (Le,aT pping�,m.e,IeakaetWor,uoc la,m.) y Installed <br /> T N <br /> A <br /> N <br /> K <br /> P ❑ Approved Approved with conditions L1 Disapproved <br /> L <br /> A (See Attachment With Conditions) <br /> N Plan Reviewers Name Date <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY,ENVIRONMENTAL HEALTH DEPARTMENT.ON4JER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING 9 CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT <br /> TO WORKERS CONDENSATION LAWS OF CALIFORNIA' CONTRACTORS HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OFCALIFCRVIA' /7 <br /> Applicants Signetlae Title C ntrc r-- r— Date Q 1� <br /> BILLING INFORMATION: <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br /> the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this <br /> responsibility for the billing by signature and date below. <br /> NAME TITLE <br /> PHONE# <br /> ADDRESS <br /> SIGNATURE DATE <br /> EH230038(revised 02/20109) <br /> 1 <br />